Sensory Processing Disorders in Children with Autism i

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ntion and lexical acquisition style. ache, J. S. (2004). From the innorelopment of pictorial competence. evelopment and behavior (Vol. 32, ress. communication in verbal children. with autism: Strategies to enhance .33-162). Albany, NY: Delmar. Ian condition through communica& W. Ishaq (Eds.), Contemporary Ce human condition (pp. 207-231).

Sensory Processing Disorders in Children with Autism

I communication in HFA and AS. In hnce (Eds.), Asperger syndrome or ) . New York: Plenum Press. herview. In S. W. Blackstone (Ed.), )duction (pp. 1-28). Rockville, MD: ssociation. A follow-up study of high-function'sychology and Psychiatry, 33, 489-

Nature, Assessment, and Intervention

Eynat Gal Sharon A. Cermak Ayelet Ben-Sasson

neasuring social communication in .s. In T. Charman & W. Stone (Eds.), lent in autism spectrum disorders: vtervention (pp. 3-34). New York: nson, T. A. (1998). Communicative, of young children with autism and nerican Journal of Speech-Language 84). Profiles of communicative and Idren. Journal of Speech and Hearing .tment of responding to and initiating Stone (Eds.), Social and communicadisorders: Early identification, diag). New York: Guilford Press.

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Children and adolescents with autism often present with sensory processing disorders. In addition to communication and social core deficits, autism is defined by restricted stereotyped behaviors (American Psychiatric Association, 2000). These behaviors include sensory and motor aspects such as unusual sensory interests and stereotyped body movements. Additional sensory-motor features often associated with autism include over- and underresponsivity to sensations, clumsiness, and abnormal postures (O7Neill & Jones, 1997). Firsthand accounts of adults with autism reveal their unusual sensory experiences including sensitivity, distortions in sensory perception, and fascination with the details of sensory input (Grandin, 1995; Grandin & Scariano, 1986; Jones, Quigney, & Huws, 2003; Shore, 2001; Williams, 1998). Several scholars have suggested that sensory processing symptoms underlie the core social and communication deficits in autism (Ornitz, Guthrie, &

THE INDIVIDUAL WITH AUTISM

Farley, 1978; Talay-Ongan & Wood, 2000). It is important to address sensory processing disorders, as they have been significantly associated with impaired daily living skills (Kay, 2001; Liss, Saulnier, Fein, & Kinsbourne, 2006) and elevated anxiety and depressive symptoms in children with autism (Pfeiffer, Kinnealey, Reed, & Herzberg, 2005). Various intervention methods have been applied to address sensory processing d~sordersin persons with autism in the form of dlrect sensoryintegrative intervention, caregiver consultation, environmental and task adaptations, and the design of "sensory diets." These interventions aim to improve self-regulation and participation in activities of daily life. The goal of this chapter is to (1)define sensory processing concepts and theory, (2) describe the nature of sensory processing disorders in children with autism, (3) demonstrate how these disorders may impact the participation of children with autism and their families in activities of daily living, and (4) outline the assessment and intervention methods used by occupational therapists to address sensory processing disorders in chlldren with autism. Although this chapter focuses on types of sensory modulation and sensory processing disorders, motor issues that relate to sensory processing disorders are briefly reviewed. (See Leary & Hill, 1996, and Smith, 2004, for reviews of motor disorders in autism.)

SENSORY PROCESSING CONCEPTS AND THEORY Sensory processing is a comprehensive term that refers to the way in which the nervous system manages sensory information, including the registration, modulation, integration, and organization of sensory input (Miller & Lane, 2000). Ayres (1985) described the human brain as a "sensory processing machine," as over 80% of the nervous system is involved in processing or organizing sensory input. Children and adults have characteristic ways of processing sensory information. For some people, particular sensory experiences are pleasurable, while these same sensory events are innocuous or noxious to others. Each way of responding to, or experiencing, sensation may have a corresponding pattern of behavior (Huebner & Dunn, 2001). However, for individuals with a sensory processing disorder these differences are extreme and may Interfere with daily functioning (Miller, Lane, Cermak, Osten, & Anzalone, 2005)

Classification of Sensory Processing Disorders Since the 1960s. sensory processing disorders have been defined by occu-

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2000). It is important to address nave been significantly associated y, 2001; Liss, Saulnier, Fein, & lety and depressive symptoms in :y, Reed, & Herzberg, 2005). Varpplied to address sensory process1 in the form of direct sensorysultation, environmental and task ry diets." These interventions aim pation in activities of daily life. lefine sensory processing concepts f sensory processing disorders in how these disorders may impact s m and their families in activities :ssment and intervention methods jress sensory processing disorders s chapter focuses on types of sensing disorders, motor issues that are briefly reviewed. (See Leary & YS of motor disorders in autism.)

INCEPTS AND 'THEORY term that refers to the way in which nformation, including the registranization of sensory input (Miller & ne human brain as a "sensory pronervous system is involved in prolildren and adults have characterisation. For some people, particular rhile these same sensory events are Nay of responding to, or experiencig pattern of behavior (Huebner & : with a sensory processing disorder ly interfere with daily functioning alone, 2005)

rders sorders have been defined by OCCUms (Ayres, 1965, 1972). ~ecently, :lopmental and Learning iso orders

Sensory Processing Disorders

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(JCDL)task force revised the Zero to Three (2005)classification of regulatory sensory processing disorders (Miller et al., 2005). The ICDL classification was designed for young children; however, it is clinically relevant for older children as well. According to the ICDL model there are three types of sensory processing disorders: sensory modulation, sensory discrimination, and sensory-based motor disorders.

Sensory Modulation Sensory modulation is one component of sensory processing and is defined as the ability to regulate and manage one's response to sensory input from auditory, visual, tactile, vestibular, and oral modalities in a graded and adaptive manner (Mulligan, 2002). Dunn (1997) defined sensory modulation as the ability to balance habituation and sensitization. Habituation is the ability of the nervous system to recognize a stimulus as familiar and to stop responding to that stimulus, for example the feel of clothing on our skin. Sensitization is the nervous system's ability to identify important or harmful stimuli and respond accordingly, for example responding to a fire alarm. Children with a sensory modulation disorder have difficulties regulating and organizing the degree and intensity of responses to sensory input in multiple sensory modalities. They are diagnosed based on their behavioral presentation; however, it is hypothesized that this disorder reflects atypical neurological responses of habituation and sensitization responses (Dunn, 1997). There is research that supports this hypothesis. For example, in an electrodermal response study, children with a sensory modulation disorder either showed reduced physiological response to sensations or showed more distinctive electrodermal responses, and were slower to habituate to sensations than children without a sensory modulation disorder (McIntosh, Miller, Shyu, & Hagerman, 1999). Sensory modulation disorders consist of three subtypes: sensory overresponsivity, sensory underresponsivity, and sensory seeking (Miller et al., 2005). Sensory overresponsivity is defined as exaggerated, rapidonset, or prolonged reactions to sensory stimulation (Miller et al., 2005). It is hypothesized that children who are overresponsive to sensory input may lack the ability to habituate their response to background stimuli. Children with overresponsivity tend to respond to sensory stimuli with anxiety, fearfulness, avoidance, andlor negative and oppositional behavior. Sensory underresponsivity is defined as a lack of awareness or slow response to sensory input of typical intensity (Miller et al., 2005). This Pattern is also referred to as a low registration pattern, which describes the child's difficulty noticing sensation. It is hypothesized that this


behavioral response may reflect overhabituation. The child with underresponsivity may appear self-absorbed, uninterested, lethargic, passive, or slow in reacting to various stimuli. Sensory seeking is defined as craving of and interest in sensory experiences that are prolonged or intense compared with those that appeal to typical children (Miller et al., 2005). Children with a sensory seeking pattern tend to be active, impulsive, and restless. These three types of sensory modulation disorders are comparable to the four patterns of sensory modulation disorders defined by Dunn (1997): (1)sensory avoiding, (2) sensory sensitivity, (3) low registration, and (4)sensory seeking. Sensory avoiding and sensitivity are comparable to sensory overresponsivity, low registration is comparable to underresponsivity, and sensory seeking is a subtype in both models.

Sensory Discrimination Sensory discrimination is the processing of spatial and temporal qualities of touch, movement, or body position, as well as vision and audition, and is important for skill development (Koomar & Bundy, 2002). For example, tactile input coming in through the skin receptors of the body provides information about the size, shape, and texture of objects. If a child were to put his hand in his pocket and feel different objects, he would be able to tell a coin from a key without the use of vision. Children with decreased tactile discrimination, therefore, may rely overly on their visual skills and have difficulties in automatic adjustment when grasping different objects such as cups or eating and writing utensils. Children with decreased proprioceptive discrimination may show difficulty in judging the amount of force or speed needed for a task. Children with poor discrimination also often present with poor awareness of their body and with dyspraxia (Ayres, 1972; Cermak & Larkin, 2002; Koomar & Bundy, 2002; Miller et al., 2005).

Sensoiy-Based Motor Challenges Sensory-based motor challenges relate to postural disorders and dyspraxia (impairment in motor planning). Children with sensory-based motor difficulties, specifically somato-dyspraxia, often exhbit poor tattile and proprioceptive processing, clumsiness, poor gross-motor skills (e.g., difficulty in catching a ball, frequent tripping), difficulty with finemotor and manipulation skills, and poor organization. They may have difficulties with balance, sequencing movements, bilateral coordination, and imitating movements (Miller et al., 2005; Rogers, 1999; Smith &


Bryson, 1994). Such difficulties are especially pronounced when the child learns a new motor skill and requires increased practice compared to typical children in order to automate the new skill.

tion. The child with underiterested, lethargic, passive, of and interest in sensory compared with those that 5 ) . Children with a sensory , and restless. ~ndisorders are comparable disorders defined by Dunn sitivity, (3) low registration, d sensitivity are comparable In is comparable to underpe in both models.

?atial and temporal qualities ell as vision and audition, omar & Bundy, 2002). For e skin receptors of the body and texture of objects. If a nd feel different objects, he without the use of vision. ation, therefore, may rely ties in automatic adjustment ; or eating and writing uten-e discrimination may show )r speed needed for a task. :n present with poor aware:s, 1972; Cermak & Larkin, l., 2005).

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THE NATURE OF SENSORY PROCESSING DISORDERS IN CHILDREN WITH AU'TISM

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postural disorders and dys:hildren with sensory-based axia, often exhibit poor tacess, poor gross-motor skills ripping), difficulty with finerganization. They may have ients, bilateral coordination, 05; Rogers, 1999; Smith & I

The prevalence of sensory modulation disorders in school-age children with autism ranges from 30% to 88% across studies (Kientz & Dunn, 1997; Le Couteur et al., 1989; Ornitz, Guthrie, & Farley, 1977; Volkmar, Cohen, & Paul, 1986; Weisblatt, Parr, & Alcantara, 2005). Wide age ranges and differences in measures among studies may have contributed to these variations. Several sensory processing studies in autism (e.g., Ermer & Dunn, 1998; Kientz & Dunn, 1997) used the Sensory Profile (Dunn, 1995), a parent questionnaire assessing sensory processing behaviors during daily activities. Parent report studies demonstrated that school-age children with autism show higher frequencies of extreme sensory processing behaviors compared with their typically developing, age-matched peers (Kientz & Dunn, 1997; Miller, Reisman, McIntosh, & Simon, 2001; Talay-Ongan & Wood, 2000; VerMaas-Lee, 1999) and compared with children with mental retardation (Sagarin, 1998). However, fewer differences were found relative to other clinical populations such as children who have blindness and deafness or receptive aphasia (Wing, 1976). It appears that some aspects of sensory processing are unique to children with autism, while other aspects are common in other clinical populations as well. It is possible that children with autism are unique in their mixed pattern of modulation disorders. Wing (1976) described children with autism as those who typically have odd and contradictory responses to sensory input, including inattention, fascination, and distress. This clinical observation was supported by evidence showing that children with autism present with more than one type of sensory modulation disorder (Liss et al., 2006), specifically overand underresponsivity (Baranek, David, Poe, Stone, & Watson, 2006; Ornitz et al., 1978). It is possible that this mixed pattern reflects a common underlying mechanism in poor sensory modulation (Dunn, 1997). Poor modulation can be expressed as difficulty maintaining an optimal level of arousal leading to exaggerated responses and fluctuation of response from under- to overresponsivity. Alternatively, underresponsive behaviors may be an attempt to shut down and avoid overwhelming sensations (Lane, 2002), and sensation-seeking responses may be the child's way of increasing arousal (Dunn, 1997).


Overresponse to Sensory Input School-age children with autism show significantly more sensory overresponsive behaviors than typically developing children (Ermer & Dunn, 1998; Kientz & Dunn, 1997; Miller et al., 2001; Talay-Ongan & Wood, 2001) and other clinical populations such as children with fragile X (Miller et al., 2001) and children with attention-deficidhyperactivity disorder (ADHD) (Ermer & Dunn, 1998). In a large-scale study of individuals with autism spectrum disorders (n = 248), 80% of parents reported negative sensory reactions by their child (e.g., dislike of certain textures) (Weisblatt et al., 2005). Children with autism and sensory overresponsivity presented 'fight,' 'flight,' and 'fright' reactions toward sensations such as light touch and loud noises. They were also highly distracted by background sensations and showed difficulty performing in overstimulating environments.

Underresponse to Sensory lnput Underresponsivity is considered by some investigators to be the most distinguishing sensory pattern of children with autism (Rogers & Ozonoff, 2005). Children with autism who are underresponsive may appear to be deaf or may show a delayed response to extreme temperature or pain. Some parent-report studies confirm this notion by showing a significantly higher frequency of underresponsivity in school-age children with autism compared with typically developing children (Kientz & Dunn, 1997) and compared with children with milder forms of autism spectrum disorders (pervasive developmental disorders not otherwise specified [PDDNOS]) (Liss et al., 2006; Smith-Myles et al., 2004). However, other studies did not find differences in underresponsivity between children with autism and typically developing children or relative to other clinical populations (Ermer & Dunn, 1998; Miller et al.,

Sensory Seeking There is contrasting evidence regarding sensory-seeking behaviors in children with autism. In one study, children with autism showed higher frequencies of sensory-seeking behaviors compared with typical children (Kientz & Dunn, 1997) and compared with children with PDDNOS (Liss, 2002), while in another study, they showed lower frequency of

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ificantl~more sensory overng children (Ermer & Dunn, ,001; Talay-Ongan & Wood, I as children with fragile X tion-deficitlhyperactivity disI large-scale study of individIS), 80% of parents reported 3., dislike of certain textures) sm and sensory overresponsreactions toward sensations vere also highly distracted by lty performing in overstimu-

dence may relate to the fact that these studies evaluated the frequency of typical sensory seeking (e.g., seeking physical activities, touching textures), but did not focus on idiosyncratic unusual sensory interests (e.g., flicking fingers, smelling objects). In a study that examined unusual sensory interests in individuals with autism, rates were as high as 90% (Weisblatt et al., 2005), suggesting that the atypical nature of sensory seeking is important to evaluate for understanding sensory seeking in autism.

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Sensory Modalities Response to Auditory Stimuli

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Aside from evidence of the unique types of sensory responses of children with autism, there are descriptions of the specific sensory modalities involved. Gillberg and Coleman (1992) argued that abnormal reactions to sound are common in children with autism. These odd behavioral responses to sounds include ignoring some sounds, fascination with other sounds, and display of distress when presented with other sounds. All these responses may occur within the same child. In a study of 248 individuals with autism, more individuals (77%) had noise sensitivity than unusual interest in sounds (9%) (Weisblatt et al., 2005). A recent study reported that children with autism showed superior auditory discrimination abilities relative to chronological age-matched typical peers (O'Riordan & Filippo, 2006). The authors suggested that this may relate to a heightened response to background sounds in children with autism. One must consider the contribution of auditory processing symptoms to the communication deficits of children with autism (Baranek et al., 2006). For example, a child with autism and auditory processing symptoms may respond more effectively when spoken to without background noise or in a certain tone of voice. Verbal and nonverbal communication require processing of both auditory and visual input, hence a child's inability to attend to and integrate auditory and visual input may lead to great disruption in communication and behavior.

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Response to Visual Stimuli

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investigators to be the most with autism (Rogers & Ozounderresponsive may appear je to extreme temperature or this notion by showing a sig~sivityin school-age children veloping children (Kientz & with milder forms of autism ntal disorders not otherwise , Smith-Myles et al., 2004). ferences in underresponsivity y developing children or rela& Dunn, 1998; Miller et al., I 1

sensory-seeking behaviors in :n with autism showed higher ompared with typical children with children with PDDNOS y showed lower frequency of I typically developing children n, 1998). This contrasting evi-

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In addition to atypical auditory responses, atypical responses to visual stimuli are present in many children with autism. In contrast with the auditory modality, more parents report visual interests than visual sensitivities in their child with autism (Weisblatt et al., 2005). Visual-seeking behaviors include fascination with geometrical figures, close visual


examination of objects, and twirling and spinning of circular objects. Unusual visual responses observed in persons with autism include sensitivity to light, especially bright, flashing, or blinking lights, and difficulty finding things due to visual overload (McMullen, 2001). Visual sensitivity may also be manifested in peripheral eye contact or gaze aversion. However, it is difficult to disentangle the sensory, emotional, and social aspects of abnormal eye contact. Response to Other Sensory Input Odd responses to proximal sensations, such as touch, movement, taste and smell, pain, and temperature, are also present in children with autism. Again, the response can be fascination, distress, or indifference. Some children with autism seem to explore the world through these proximal senses for much longer time periods than usual, while other children dislike being touched and will pull away even from gentle, affectionate touch. Some children with autism may enjoy or seek deep touch, while others may display this desire in the form of self-injurious behaviors (e.g., head banging, pinching). Some children may be bothered by the feel of certain types of clothing, especially shoes and socks. Baranek and Berkson (1994) found that children with developmental disabilities, including autism, show a higher frequency of tactile overresponsiveness based on a caregiver report and direct examination. Miller and colleagues (2001) found tactile sensitivity to be more characteristic of children with autism than children with fragile X. In the vestibular modality, some children with autism show avoidance of rnovements that require the feet to leave the ground (e.g., riding an escalator), while others may seek physical activity in the form of stereotyped movements. Unusual oral (includes taste and smell) responses are highly common in children with autism (Miller et al., 2001; Talay-Ongan & Wood, 2001; Weisblatt et al., 2005). There are children who show sensitivity to smells and negative reaction to faint odors such as perfume worn by 0thers. Other children may frequently smell objects or people. Children may seek oral stimulation by mouthing objects, biting, or eating nonedible materials. Some children restrict their diets and will accept a very small number of food choices, such as only peanut butter and jelly sandwiches, popcorn, and water. Such behavior may represent an insistence on sameness, which is a characteristic of many children with autism. However, it also may result from sensory overresponsiveness to tastes, smells, or textures, leading to a diet limited to "sensory-safe" or pfeferred foods.

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Autism and Sensory-Based Motor Disorders

~nningof circular objects. with autism include sensinking lights, and difficulty len, 2001). Visual sensitivcontact or gaze aversion. ;ory, emotional, and social

as touch, movement, taste present in children with n, distress, or indifference. : the world through these ds than usual, while other 11 away even from gentle, m may enjoy or seek deep I the form of self-injurious e children may be bothered specially shoes and socks. ildren with developmental : frequency of tactile overt and direct examination. nsitivity to be more characI with fragile X. In the vesshow avoidance of moved (e.g., riding an escalator), : form of stereotyped moveresponses are highly com101; Talay-Ongan & Wood, ken who show sensitivity to ~ c has perfume worn by 0th:cts or people. Children may biting, or eating nonedible and will accept a very small mut butter and jelly sandmay represent an insistence nany children with autism. )verresponsiveness to tastes, d to "sensory-safe" or pre-

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Autism is associated with a wide range of sensory-based motor disorders that are manifested in fine- and gross-motor impairments andlor atypical movements and postures (Dawson & Watling, 2000; Leary & Hill, 1996; Smith, 2004). Studies have shown that school-age children with autism have impairments in praxis (Smith & Bryson, 1994), gait, posture, and balance (Kohen-Raz, Volkmar, & Cohen, 1992), eye-hand coordination, finger speed (Smith & Bryson, 1998), gesture, and imitation (Rogers, 1999).

SENSORY PROCESSING DISORDERS AND OCCLIPA'I'IONS OF DAILY LIFE

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In order to facilitate the occupational performance of children and adolescents with autism, one must consider its interplay with sensory processing. Occupational performance is the participation in meaningful and purposeful activities that produce functional and successful daily living skills and routines (American Occupational Therapy Association, 2002). A school-age child's areas of occupation include performance of activities of daily life, attending school and learning, and participation in play, leisure, and social interactions with family members and peers. Adolescents are expected to be more independent in self-care, home management tasks (e.g., shaving, simple meal preparation), and leisure activities (e.g., going to the cinema with peers) and often engage in prevocational training. In the following section we discuss how different types of sensory processing disorders such as sensory over- or underreactivity, sensory seeking, and dyspraxia may impact the occupational performance and choices of children and adolescents with autism. We also refer to the influence of occupations and their context upon the expression of sensory processing disorders. Sensory processing disorders dynamically interact with other factors such as family context, environmental opportunities, and experience to shape an individual's engagement in occupations throughout the life span (Parham, 2002).

Activities of Daily Life Activities of daily life, which include self-care, home management, community mobility, health, and safety management (American Occupational Therapy Association, 2002), require the processing of multiple and unpredictable sensations within the home, school, and community

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environments. Children with sensory overresponsiveness may become highly distressed from certain textures, sounds, tastes, touches, and movements and thus avoid or resist participating in daily activities that consist of these aversive sensations (e.g., brushing teeth, using an escalator). Some children who are overresponsive to sensory input may insist on sameness in daily routines, in the clothes they wear, and in foods they eat in an attempt to increase predictability and control of sensation. The hypervigilance of children who are overresponsive to sensory input can lead to their inability to perform daily tasks in overstimulating environments, as these children may be distracted by background sounds, sights, and smells. Children with underresponsiveness may not process sensations that indicate to them that their shoe is on the wrong foot, that their nose is running, that clothing is entangled or wet, or that they are being called for dinner. These children may not initiate engaging in daily tasks and thus may need reminders to initiate and complete tasks. Children with sensation seeking may require strong input such as loud music or a weighted vest to support their participation in daily activities. Their craving for novel and intense sensation can distract them from completing daily tasks. These children may also benefit from engaging in activities that provide strong sensory input such as raking leaves, mowing the lawn, or vacuuming (although the noise of the vacuum cleaner may be intolerable to children who have auditory sensitivity). Another aspect of daily activities affected by sensory processing disorders is one's ability to maintain and manage health and to respond to safety hazards. Children with underresponsiveness, who barely feel pain, may not report a severe injury and thus may walk on a broken foot for days, causing further damage. Such children may be prone to various safety challenges such as falls and self-injury. Children who seek sensation are often risk takers and require supervision in safely completing daily tasks. Children with autism who also have a sensory processing disorder may have a restricted and unbalanced food diet, which can cause nutrient deficiencies and contribute to obesity. In addition, the emerging sexuality in teenagers may present an additional challenge to an already confused sensory system. An adolescent may not know how to cope with new body sensations, which may result in anxiety attacks and behavioral expressions (Kinnealey, Oliver, & Wilbarger, 1995). Children may become involved in excessive ~ u b l i cmasturbation 04 alternatively, engage in intensive repetitive movements such as rocking and head banging. Violent behavior toward self or others is another issue that may reflect sensory processing deficits and compromises safety. Violence can be an aggressive response toward unpleasant sensations, a result of underawareness of the amount of force applied, or a craving for intense input.

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School and Vocational Activities Sensory processing disorders can also impact participation in school and vocational activities. The physical and human educational environment may present various sensory-motor challenges for a child with a sensory processing disorder. Children who are overresponsive to sensory input and those who seek sensation often show difficulties in attending to the main stimuli presented by the teacher, and are instead preoccupied by distracting sensations such as cluttered bulletin boards and corridor sounds, or by unusual sensory components of the task. For example, the child with auditory overresponsiveness may have difficulty participating in an inclusive classroom or school cafeteria in which the noise level is high. Similarly, a teacher's high-pitched voice may interfere with the child's ability to listen to the content of what is being said. Seeking behaviors, distractibility, and unawareness of input may impact a child's ability to follow instructions and focus on tasks. Children who are underresponsive to sensory input can become self-absorbed in a task, unaware of the time or the fact that the class has already transitioned to a different task. Children with sensory-based motor disorders may show difficulties in learning to manipulate new objects and utensils. Factors that can impede participation in educational and prevocational training settings include issues related to proximity to other students, sounds, lighting, schedule of breaks, duration of time in seat, and material arrangement. An organized setting with a fixed schedule can increase a child's successful participation in these settings. Later in life, sensory processing challenges may affect vocational skills and choices. For example, a person with autism may not be able to work in environments that present a lot of sensory stimulation, especially noisy environments, and may be so self-absorbed that he or she does not attend to danger signs in the working place.

Leisure Activities Sensory processing influences how, where, and with whom we spend our leisure time. Leisure, which is the "fun time" for most typical children, may pose a great many demands on children with autism. Many typical leisure settings are highly stimulating (e.g., playground, mall, gym) and thus do not suit children with a sensory processing disorder. Playgrounds require fast response to input, which is difficult for children with underresponsiveness or dyspraxia. Their inability to respond in a timely manner can put them at risk for injury. In addition, learning complex sport activities or engaging in hobbies that require fine-motor skills can be challenging for a child with dyspraxia. Children with overresponsive-

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ness to sensory input may avoid arts and crafts activities, as many of these activities require touching messy materials. They may prefer to engage in sedentary and familiar leisure activities with low motor demands to limit unpredictable stimulation and avoid motor challenges. Children who seek sensation might choose to engage in intense leisure activities such as bike riding, skiing, or viewing fast-paced TV programs.

Friendships and Interactions Deficits in social interactions are a core feature of autism. Social isolation may not only be a matter of social-communication deficits, but also a by-product of sensory-motor deficits. Human interactions expose all involved people to various sensory stimuli, often unpredictable in nature. A child with sensory overresponsiveness may withdraw from or avoid interactions in order to avoid unpredictable stimuli such as surprising touches and sudden noises. Children who seek sensation may touch or smell their peers in an inappropriate manner, which can lead to ridicule or rejection from peers. Children who are underresponsive may often be slow to respond to their peers' initiations, thus causing lack of communication. Children who have dyspraxia may avoid playing any kind of game that requires motor coordination, which, for many of their peers, may be a preferred activity. Therefore mismatches between the sensory processing of children with autism who also have a sensory processing disorder and their peers' sensory processing may directly impact the friendships and interactions of children with autism. Table 5.1 presents examples for possible implications of various sensory processing disorders such as sensory overresponsivity, sensory underresponsivity, sensory seeking, and sensory-based motor challenges for children's occupations in their everyday lives.

ASSESSMENT OF SENSORY PROCESSING DISORDERS Given the high incidence of sensory processing disorders in children with autism, assessment of sensory-motor functions is essential. Assessment typically serves as the initial step of the intervention process and should provide sufficient information to guide therapists and families in setting goals, determining the appropriate model for service delivery, and evaluating change. However, assessment is almost always an ongoing process, especially for children with autism, for whom a myriad of internal (e.g., seizures) and external (e.g., moving into a new class) factors influence function (Mailloux, 2001).

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TABLE 5.1. Examples of Implications of Sensory Processing Disorders for Occupations of Children with Autism Sensorv overreactivity

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Sensow underreactivitv

Sensorv seekine

Dvs~raxia

Activities of daily life

Resists nail and hair trimming. Wears long-sleeved shirts all year round.

Unaware of mess on hands or face. Does not adapt clothing to room temperature.

Twirls shoelaces instead of tying them.

Difficulty lacing and fastening shoes. Difficulty in sequencing the steps of dressing.

Health

Melts down when hears a fire drill. Eats only soft-textured foods such as yogurts.

Lack of response to pain, extreme temperature, or injury. Does not attend to street cues when crossing the street.

Bangs head, jumps from heights. Eats nonedible materials. Runs into the street.

Prone to falls and accidents. Difficulty following fire safety procedures.

Learning

Overwhelmed and distracted by fluorescent lights in classroom.

Does not follow oral instructions.

Difficulty staying in seat for extended periods of time and fidgety.

Difficulty in learning new skills and preference for familiar activities.

Vocational training

Difficulty working in noisy environments.

Lack of attention to danger signs at work. Highly focused on task.

Perseverates on one sensory aspect of the job ignoring job demands.

Preference for tasks that require few motor skills, such as computer work, library work.

Leisure

Anxious at, or avoids going to, a movie or mall.

Slow response to moving swings or passing bike riders.

Engages in self-stimulation or unusual sensory interests (water play, wheel spinning). Seeks intense input through jumping, or loud music.

Difficulty in learning to ride a bike, swim, or play baseball, resulting in reduced participation with peers.

Friendships1 social interaction

Overwhelmed by unexpected pushing and yelling of children during recess.

Bumps into others Squeezes friend's hand instead of shaking.

Sniffing or rocking may lead to social rejection.

Limiting interests to nonmotor activities and enforcing restricted interests on uninterested peers.

Family life

Distressed by changes in family routines. Avoids of touch~hugs/kisses from parent.

Does not notice facial expressions of family members.

Spinning plates or yelling in a restaurant.

Demands preplanned family activities. Limited participation in family sport activities.

THE INIIIVIDUAL WITH AUTISM

The assessment process should include an examination of the child's sensory and motor assets and needs, their impact upon daily occupations, the sensory and motor features of tasks and environments where the child wants to and is expected to perform, and the "fit" of these environments with the child's needs. Such an assessment should answer the following questions: (1)Is the child's response to sensation different in frequency and quality from that of typically performing children, and to what extent? (2) How do these behaviors impact child and family occupations, routines, and well-being? and (3) How do these differences interact with the child's environment and task demands? It is important to evaluate behaviors in different settings and at different times of the day, as sensory behaviors may be more pronounced at certain places and times than at others. For instance, in the school cafeteria a child with overresponsivity may be highly distressed by sensations and respond by not eating, while at home mealtimes may occur in a less stimulating or challenging environment and therefore the child is able to eat. Information about a child's sensory processing is gained through caregiver report, direct assessment, and clinical observation. Sensory histories and questionnaires provide important insights into various aspects of sensory processing that are not always apparent through direct assessment or observation. Based on parent-completed questionnaires, therapists evaluate where the child is on a scale of over- and underresponsiveness, specifically within various sensory modalities. The onset, duration, and inten&- of the behavioral responses are noted as well. Sensory history checklists comprise the majority of standardized, norm-referenced measures of sensory modulation and primarily assess the frequency of sensory behaviors within daily contexts (see Table 5.2 for examples of standardized measures for evaluating sensory processing disorders in school-age children). There are additional sensory processing questionnaires described in research protocols for children with autism (e.g., Baranek et al., 2006; Liss, 2002) that include the evaluation of unusual sensory responses characteristic of these children. Standardized tests of sensory processing that are directly administered to the child focus on motor planning and sensory-based motor skills rather than sensory modulation. Direct testing may not be feasible for some children with autism due to their communication deficits, short attention span, and difficulties ~erformingin unfamiliar settings. Thus, alternative types of assessment in the child's natural environment may be required. Although standardized assessments focus ~rirnarilyon the child's characteristics or skills, in practice, occupational therapists use various observations and apply their knowledge of sensory ~rocessingand task

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analysis to evaluate environmental supports and barriers to participation. This is important for understanding the 'impairing' nature of a child's sensory processing deficits and their expression in his or her natural environment. There are participation-based measures such as the School Functional Assessment (Coster, Deeney, Haltiwanger, & Haley, 1998) that are not specifically designed to assess sensory processing disorders, but rather to assess broader areas of functioning (e.g., transitioning between classes, using class materials) that may be affected by sensory processing disorders. The gross- and fine-motor skills of the child should be examined, including motor planning. These are usually assessed through direct testing of the child rather than questionnaires. The "gold-standard" assessment for sensory discrimination and praxis is The Sensory Integration and Praxis Tests (Ayres, 1989),'a set of 1 7 tests designed to assess aspects of sensory processing and motor planninglpraxis. This test is standardized for children ages 4 through 8 years. Other standardized tests that assess motor skills are described in Table 5.3. Many children with motor planning problems also have difficulty in visual-motor integration and handwriting, therefore assessment of these areas is also The repetitive and stereotyped movements of the child should also be assessed. Assessment should examine their presence as well as their function (e.g., increase arousal level, provide intense stimuli, avoid overstimulation) and context. Various studies (e.g., Baranek, Foster, & Berkson, 1997; Gal, Dyck, & Passmore, 2002) suggest that these movements, often called "self-stimulatory movements," may have a sensory base. The assessment of stereotyped movements can provide information about the child's atypical patterns of movement and may contribute to understanding the child's way of processing sensory information.

OCCUPATIONAL THERAPY INTERVENTIONS FOR SENSORY PROCESSING DISORDERS IN CHILDREN WITH AUTISM The main goal of occupational therapy is to enable the child to participate in typical everyday occupations. Interventions involve planning, implementation, and review of outcome (American Association of Occupational Therapy, 2002). There are four primary modes of intervention that address sensory processing disorders in children with autism; these include direct therapeutic intervention, education and consultation within home and school environments, accommodations, and self-

~ n dbarriers to participae 'impairing' nature of a cession in his or her natued measures such as the y, Haltiwanger, & Haley, assess sensory processing eas of functioning (e.g., rials) that may be affected hild should be examined, isessed through direct testle "gold-standard" assessP The Sensory Integration ' tests designed to assess ~nninglpraxis.This test is years. Other standardized Table 5.3. Many children culty in visual-motor inte:nt of these areas is also ts of the child should also r presence as well as their

de intense stimuli, avoid ; (e.g., Baranek, Foster, & !) suggest that these move:nts," may have a sensory ts can provide information ent and may contribute to sensory information.

IVENTIONS SORDERS ISM enable the child to particitentions involve planning, :rican Association of Occulary modes of intervention in children with autism; education and consultation ccommodations, and self-


employed strategies. All or some of these intervention modes may be applied in 'the intervention plan for a child with autism, depending on the child's needs, the response to intervention, and the resources available. Intervention should be provided or supervised by an occupational therapist trained in sensory integration to assure quality care and safety.

reframing, sensory nc overrespon room with rather tha

Direct Therapeutic Intervention Direct therapeutic sensory intervention is a key component in the process of treatment and takes place in the form of occupational therapy, using a traditional sensory integrative approach on a one-to-one basis in a room with suspended equipment for a variety of movement and sensory experiences (Ayres, 1972). The goal of therapy is not to teach specific skills but to follow the child's lead and artfully select and modify activities according to the child's responses in order to provide appropriate sensory input and elicit adaptive responses. Adaptive responses are goal-directed behaviors that enable an individual to meet with new or changing environmental challenges. The activities designed in this type of intervention afford a variety of opportunities to experience tactile, vestibular, and proprioceptive input in a way that provides the "just right" challenge for the child in order to promote increasingly complex adaptive responses to environmental challenges (Schaaf & Anzalone, 2001). Direct therapeutic intervention is also an opportunity for the therapist to examine which sensations have calming versus arousing effects on the child. This model of intervention requires specialized equipment and typically takes place outside the classroom. Thus, it is important to combine direct therapeutic intervention with other types of intervention methods (Baranek, 2002).

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Education and Consultation Education and consultation is a process that involves reframing a student's behavior within a sensory perspective and facilitating problem solving and strategy development (Bundy, 2002). Therapists can reframe teachers', parents', and peers' views of a student's behavior by providing them with an understanding of sensory processing disorders and their possible impact on everyday activities. If caregivers learn to view their child's sensory behaviors of avoidance and inattention (e.g., avoidance of eye contact or hugs) as a sensory response and not as rejection, lack of interest, or low motivation, they may become more tolerant of the child's atypical sensory behaviors. Such consultation can empower caregivers by giving them basic explanations for their child's behaviors

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lese intervention modes may be child with autism, depending on vention, and the resources avail)r supervised by an occupational to assure quality care and safety.

is a key component in the prole form of occupational therapy, pproach on a one-to-one basis in a variety of movement and sena1 of therapy is not to teach sped and artfully select and modify ises in order to provide appropri:sponses. Adaptive responses are individual to meet with new or ie activities designed in this type portunities to experience tactile, n a way that provides the "just to promote increasingly complex challenges (Schaaf & Anzalone, 1 is also an opportunity for the .s have calming versus arousing intervention requires specialized utside the classroom. Thus, it is c intervention with other types of I

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that they may have previously viewed as unusual, inexplicable, or confrontational. During facilitation of problem solving, the step following reframing, therapists enable caregivers to identify effective strategies for interacting and working with their child in ways that match their child's sensory needs (Bundy, 2002; Miller et al., 2005). For instance, an overresponsive child may be more likely to look at a parent in a dimmed room without visual distractions or to enjoy play involving firm hugs rather than tickling. In addition, occupational therapists have the knowledge and tools to assist parents and teachers in modifying the human and nonhuman environment, task demands, and routines to optimize the fit between the child and sensations in the home or school environment. For instance, if the mother of a child with overresponsivity to smell refrains from wearing perfume, this may reduce the child's negative response when interacting with her. Consultation often consists of developing a "sensory diet" for a child and supervising caregivers and teachers in carrying it out, a method described hereafter. Consultation does not end in planning strategies for others but requires close evaluation of the effectiveness of program implementation and modification of the program as needed. One of the key factors for the success of interventions is the partnership developed between the consulting therapist and the caregiver or teacher, a relationship that is based on trust, respect, and open communication (Bundy, 2002). It is expected that through consultation caregivers and teachers will gain a sensory perspective on a child's difficult behaviors, improve their parenting and teaching skills, and create environmental changes that will facilitate the child's successful performance.

Sensoty-Based Accommodations

,ss that involves reframing a stuipective and facilitating problem dy, 2002). Therapists can reframe a student's behavior by providing ry processing disorders and their , If caregivers learn to view their : and inattention (e.g., avoidance ?onse and not as rejection, lack of ly become more tolerant of the 1 consultation can empower caretions for their child's behaviors

Sensory-based accommodations address the child's sensory processing needs throughout the day and within the natural context. These accommodations are commonly implemented through an individualized sensory diet, a carefully planned, practical program of specific sensory activities designed to provide the optimal amount and types of sensation the child needs. The sensory diet is based on the notion that controlled sensory input can affect arousal, alertness, and attention level, and thus affect a child's ability to function (Wilbarger, 1995). An effective sensory diet enables a child to feel calm, alert, and organized and thus enhances occupational performance. It can also help the child with self-regulation, which is the ability to attain, maintain, and change levels of alertness needed for a task or situation (Williams & Shellenberger, 1994). The sensory diet provides the child with opportunities to receive beneficial


sensory input at frequent intervals, thereby enabling the child to more fully participate in daily activities. It is important to recognize that preferred input varies from child to child, and sometimes from day to day or hour to hour, depending on the child's arousal level. Many behaviors common in children with autism, such as jumping, repetitive running, head banging, chewing on nonfood objects, masturbating, biting or hitting oneself or others, or hand flapping may be the result of a need for input to the muscles and joints (proprioceptive input). Sensory diet activities often provide proprioceptive, deep touch, pressure, or vestibular input in a more socially or contextually appropriate way, such as wearing a weighted vest (Fertel-Daly, Bedell, & Hinojosa, 2001), having a massage (Escalona, Field, Singer-Strunck, Cullen, & Hartshorn, 2001), or receiving deep pressure using a "therapressure brush" (Wilbarger, 1995). In addition to, or as part of, the sensory diet, the occupational therapist often makes recommendations for accommodations that will afford the child greater opportunities for success throughout the day. A firm hug, wrapping a child in a blanket, or sitting on a vibrating pillow are some examples of such accommodations aimed at assisting children to regulate and organize their behavioral responses and helping them to decrease negative reactions to sensory input. "Heavy work" activities such as jumping on a firm pillow or trampoline, riding bicycles, swimming, stacking chairs, or a supervised exercise program (e.g., running, weightlifting) for older children may provide similar benefits (Escalona et al., 2001). For older students, therapists collaborate with caregivers and with students themselves to identify sensory activities that are age and developmentally appropriate, goal-directed, and functional. There are also accommodations and strategies designed to meet the needs of children who have sensory-based motor difficulties such as dyspraxia. Children with dyspraxia have difficulty organizing and planning their motor actions and, therefore, often have difficulty varying their play, learning complex motor skills, or transitioning between activities. Familiar routines are very important for children with motor planning difficulties. Use of visual cues may assist the child with completing multistep tasks and with the many transitions expected in a school day. For example, a timer that clearly shows the passing of a prescribed time can help a child to anticipate the end of an activity. Also, pictures of the child's daily activities can be presented to the child prior to a daily routine to assist in reminding the child of the steps involved in routines and to help explain new ones. Children with dyspraxia may benefit from simple step-by-step directions for novel activities using the sensory modality that is the most efficient for them. For example, a child for whom the auditory modality is the most efficient will benefit the most

from ver clues car modality Chi1 due to p. tant to o ioral resl modulati result of autism m or colors tolerance to use pr pops or mouth pr decreasin better ch, of a weig mats) mz back abc head, shc of a chilc or prior

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enabling the child to more Irtant to recognize that presometimes from day to day ousal level. Many behaviors jumping, repetitive running, masturbating, biting or hity be the result of a need for ve input). Sensory diet activuch, pressure, or vestibular xopriate way, such as wear: Hinojosa, 2001), having a hllen, & Hartshorn, 2001), pressure brush" (Wilbarger, nsory diet, the occupational lr accommodations that will lccess throughout the day. A sitting on a vibrating pillow 1s aimed at assisting children ,sponses and helping them to ut. "Heavy work" activities )oline, riding bicycles, swimrcise program (e.g., running, de similar benefits (Escalona s collaborate with caregivers ensory activities that are age :cted, and functional. .rategies designed to meet the d motor difficulties such as ifficulty organizing and planoften have difficulty varying r transitioning between activfor children with motor plan;ist the child with completing ons expected in a school day. :passing of a prescribed time activity. Also, pictures of the the child prior to a daily rousteps involved in routines and dyspraxia may benefit from activities using the sensory :m. For example, a child for efficient will benefit the most


115

from verbaI instructions, while hand-over-hand instructions and touch clues can be more beneficial with the child for whom the kinesthetic modality is preferred. Children with autism frequently have difficulty with self-care tasks due to problems tolerating or responding to sensory input. It is important to observe the child's reactions in order to determine if some behavioral responses during daily living activities reflect difficulty in sensory modulation or in motor planning or both. Some behaviors may be the result of tactile, taste, or smell oversensitivity. For example, a child with autism may have strong preferences for foods with similar tastes, shapes, or colors. Introducing new foods slowly may help the child to develop tolerance and interest in a greater variety of foods. It also may be helpful to use preferred foods to entice children to try novel foods. Using ice pops or frozen juice ice cubes or applying firm pressure around the mouth prior to eating may be helpful to desensitize the mouth area, thus decreasing the tactile sensitivity in that area and preparing the mouth for better chewing and swallowing. In order to improve self-feeding, the use of a weighted fork or spoon or nonslip surfaces under plates (e.g., dycem mats) may be helpful. The weight gives the child enhanced sensory feedback about where his arm is in relation to his body. Firm pressure to the head, shoulders, legs, and fingers may also provide calming preparation of a child's sensory system before cutting hair and nails, at shower time, or prior to or after putting socks on.

Sensory-Based Self-Employed Strategies Self-employed strategies are aimed at providing children with tools that are helpful in coping with unpleasant sensory experiences, can be independently employed, and can be accessed in "real time." Self-employed strategies are particularly relevant for older children and adolescents with autism, who are expected to be more independent and may receive few intervention hours. Therefore, it is important to find strategies that a person with autism can implement with minimal supervision. An example of such a program is Sensory Stories, which is designed to help children with sensory overresponsiveness successfully engage in activities within their home, school, and community environment (Marr & Nackley, 2006). Sensory Stories comprise 30 individual stories about daily activities that instruct the child to use calming sensory strategies in order to deal with the unpleasant sensory aspects of a particular situation. When read on a regular basis, Sensory Stories can help the child develop effective routines to manage sensory experiences surrounding typical daily activities. Sensory Stories use a variety of self-employed

116


strategies and may be adapted to a specific child's needs (Marr & Nackley, 2006). Another self-employed strategy is the Alert Program, which supports children, teachers, parents, and therapists in choosing appropriate strategies to change or maintain states of alertness in the child. In this program, students learn to identify their level of alertness and learn what they can do before or during stressful times to attain a more optimal state of alertness to engage in tasks. Both Sensory Stories and the Alert Program incorporate a cognitive strategy approach to helping the child with self-regulation of sensory input. Because of the cognitive demands, this approach may not suit children with autism who are lower functioning; however there are ways to apply the principles of these strategies to children with lower cognitive abilities, such as creating a picture book with pictures of calming activities that the student can perform independently.

THE INTEGRATION OF SENSORY-MOTOR INTERVENTIONS WITHIN EDUCATIONAL PROGRAMS Sensory-motor interventions can be applied within broader educational programs for children with autism. Using an inclusive approach, occupational therapists can consult with educators about ways to incorporate sensory-based intervention principles into the child's education plan (Baranek, 2002) to assist in achieving the child's educational goals within specific educational programs. For example, in an intensive Applied Behavior Analysis program, sitting for an extended period of time can challenge children who seek sensation or can result in further reduction of arousal in children who are underresponsive. For these children, incorporating sensory-based physical activity within the child's training schedule may be crucial for achieving an optimal arousal level. Understanding sensory processing preferences can also assist in selecting effective reinforcements for behavioral programs. In the Floor Time program (Greenspan & Wieder, 1998), occupational therapists can guide caregivers in engaging the child by using sensations that the child is more likely to respond to and by designing sensory-motor aspects of the play setting. In TEACCH (Treatment and Education of Autistic and related Communication-handicapped CHildren) programs (Mesibov, 1996), sensory activities can be included in the child's ~ictorial activity schedule, and environmental accommodations can be integrated

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I R INTERVENTIONS IGRAMS within broader educational n inclusive approach, occuors about ways to incorpoto the child's education plan e child's educational goals : example, in an intensive ; for an extended period of tion or can result in further lerresponsive. For these chilI activity within the child's .ng an optimal arousal level. es can also assist in selecting ograms. In the Floor Time xcupational therapists can ;ing sensations that the child ning sensory-motor aspects ~t and Education of Autistic CHildren) programs (Mesilded in the child's pictorial .modations can be integrated ance goals in such programs. .ate with educators in design-

117

ing effective instructional materials (e.g., visual cues), educational settings, sensory activities, and reinforcements to match the child's sensory and motor needs within the educational system.

EFFICACY OF SENSORY-MOTOR INTERVENTIONS FOR CHILDREN WITH AU'I'ISM Sensory and motor intervention approaches are commonly implemented by occupational therapists treating children with autism (Watling, Deitz, Kanny, & McLaughlin, 1999). However there are no rigorous, largescale experimental studies that examine the efficacy of sensory and motor interventions for these children (Baranek, 2002; Dawson & Watling, 2000). Case-study, single-system, and small-group research indicates that children with autism who receive sensory-based interventions show gains in their social and communication skills as well as a reduction of stereotyped behaviors (Ayres & Tickle, 1980; Linderman & Stewart, 1999; Reilly, Nelson, & Bundy, 1984; Zissermann, 1992). Other positive outcomes include increased modulation of the child's arousal level, self-regulation, and attention. Edelson, Edelson, Kerr, and Grandin (1999) studied the efficacy of a deep pressure intervention for 12 children with autism, which involved the engagement in a "hug machine.'' Following this intervention, there was a reduction in behavioral measures of tension and anxiety, as well as in physiological measures of anxiety. Since the outcome of sensory and motor interventions is described in heterogeneous, small-scale, uncontrolled studies, there is a need to close the gap between sensory practice and evidence (Rogers & Ozonoff, 2005). When assuring the quality of a sensory and motor intervention for children with autism, Baranek (2002) recommends close examination of the (1)feasibility within the educational program, (2) cost, (3) maintenance of the outcome across time, and (4) generalizability to other settings.

CONCLUSION In addition to the core social, communication, and behavioral characteristics of autism, sensory and motor problems can also have a major impact on the occupational performance of children with autism. Sensory-motor difficulties of children with autism can not only create a source of frustration and anxiety, but may further increase their social isolation. This chapter outlined the process of assessment and interven-

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tion for sensory processing a n d m o t o r planning issues. Gaining a sensory perspective o n behavior may assist parents a n d professionals i n understanding many of the child's atypical behaviors, i n finding ways t o modify the human a n d nonhuman environment to meet sensory a n d motor needs, and in learning h o w to implement strategies to promote adaptive behaviors. As occupational therapists, w e hope that such interventions will enable the individual with autism t o enjoy daily sensations and become a more active a n d interactive participant i n society.

ACKNOWLEDGMENTS Ayelet Ben-Sasson was supported by The Wallace Research Foundation grant awarded to Dr. Alice Carter a t the University of Massachusetts and Dr. Margaret Briggs-Gowan at Yale University.

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